Provider Demographics
NPI:1295006260
Name:WEITZMAN, TRACY LYNN (MA TLLP)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LYNN
Last Name:WEITZMAN
Suffix:
Gender:F
Credentials:MA TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20300 CIVIC CENTER DR.
Mailing Address - Street 2:STE. 3030
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4169
Mailing Address - Country:US
Mailing Address - Phone:248-559-8190
Mailing Address - Fax:248-559-8776
Practice Address - Street 1:20300 CIVIC CENTER DR
Practice Address - Street 2:STE. 303
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4105
Practice Address - Country:US
Practice Address - Phone:248-559-8190
Practice Address - Fax:248-559-8776
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2082501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION90430Medicare UPIN